A typology of people who tamper with pharmaceutical opioids: responses to introduction of a tamper-resistant formulation of controlled-release oxycodone

Alprazolam use among a sample of Australians who inject drugs: Trends up to six years post regulatory changes

INTRODUCTION

Alprazolam is a high potency triazolobenzodiazepine that is associated with a disproportionate amount of harm compared to other benzodiazepines. In Australia, amid growing concerns of extra-medical use and harms, alprazolam was up-scheduled from Schedule 4 (prescription only) to Schedule 8 (controlled drug) on 1 February 2014, with further restrictions introduced on 1 February 2017. This study aims to examine the impact of these regulatory changes among cross-sectional samples of people who inject drugs (PWID), from 2011-2019.

METHODS

Data were obtained from the 2011-2019 Illicit Drug Reporting System, comprising cross-sectional samples of PWID recruited annually from Australian capital cities (approximately ~900 per year).

RESULTS

By 2019, the proportion of PWID who reported past six-month use of non-prescribed (17%) and prescribed (4%) alprazolam had halved compared to 2011 (39% and 13%, respectively), with no evidence of an increase in use of other sedative substances. Following the up-scheduling of alprazolam in 2014, there was an increase in the median last price paid for 2 mg of diverted alprazolam ($5AUD pre-rescheduling versus $7AUD post rescheduling), with 61% of those able to answer reporting that diverted alprazolam had become 'more difficult' to obtain post versus pre-rescheduling. The correlates associated with non-prescribed alprazolam use remained relatively consistent pre- and post-regulatory change, with past-month criminal activity, past six-month opioid agonist therapy and past six-month use of non-prescribed other benzodiazepines associated with non-prescribed alprazolam use in both the 2013 and 2018 samples.

CONCLUSIONS

Regulatory changes appear to have resulted in sustained reductions in alprazolam use amongst our annual cross-sectional sentinel samples of PWID, although a considerable minority (17%) continued to report non-prescribed use in 2019. To achieve further reductions in non-prescribed use and associated harms, these regulatory changes need to be coupled with other interventions, such as direct consumer engagement and harm reduction messaging. Our findings suggest that people receiving opioid agonist therapy remain a key target population for such interventions.

Internet pseudoscience: Testing opioid containing formulations with tampering potential

Drug tampering practices, with the aim to increase availability of drug delivery and/or enhance drug effects, are accessible on Internet and are practiced by some portion of recreational drug users. Not rarely, recreational misuse may result in toxic and even fatal results. The aim of the present study was to assess the tampering risk of medicaments containing different formulations of an opioid in combination with paracetamol or dexketoprofen, following the procedures reported in dedicated forums on the web. Tablets and suppositories containing codeine, tramadol and oxycodone were extracted following the reported "Cold water extraction"; dextromethorphan was extracted from cough syrup following the procedure reported as "Acid/base extraction" and fentanyl was extracted from transdermal patches according the procedure reported in Internet. The tampered products and opportunely prepared calibrators in water were analysed by liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS). The separation of the analytes was carried on Agilent ZORBAX Eclipse Plus C18 (RRHT 2.1 mm × 50 mm, 1.8 μm) by the gradient elution of 0.01% formic acid in water and 0.01% formic acid in methanol. Acquisition was by MRM mode considering at least two transitions for compound. Declared recoveries for these home-made extractions claimed to exceed 99% for the opioid and to complete remove paracetamol, often associated to liver toxicity and thus to obtain a "safer" preparation. In this study, the authors demonstrated that rarely the recoveries for the opioid reached 90% and that up to 60% of the paracetamol amount remained in solution. Thus, high risks for health remained both for the potential lethality of the opioid content, but also for the sub-lethal chronic use of these mixtures, which contained still uncontrolled, ignored, but often important amounts of paracetamol.

The effect of a potentially tamper-resistant oxycodone formulation on opioid use and harm: main findings of the National Opioid Medications Abuse Deterrence (NOMAD) study

BACKGROUND

Escalation of pharmaceutical opioid use and harm in North America is well-documented, with similar issues emerging in Australia. One response is the development of tamper-resistant formulations of opioids. A potentially tamper-resistant formulation of controlled-release oxycodone was introduced in Australia in April, 2014, rapidly replacing the non-tamper-resistant formulation. Our study is the most systematic and comprehensive examination of the impact of a new opioid formulation to date, assessing the effect of tamper-resistant formulation of controlled-release oxycodone on population-level opioid use and opioid-related harm (ie, overdose, help-seeking, and treatment-seeking); and opioid use, tampering, and preference for the tamper-resistant formulation of controlled-release oxycodone compared with other drugs or formulations among sentinel populations likely to tamper with pharmaceutical opioids.

METHODS

We conducted interrupted time-series analyses of opioid sales data and multiple routinely collected health datasets, followed up a cohort of people who tamper with pharmaceutical opioids before and after the introduction of the tamper-resistant formulation of controlled-release oxycodone, and analysed annual surveys of people who inject drugs. Data were collected from several Australian states: New South Wales, South Australia, and Tasmania. Meta-analyses (weighted Z tests) were conducted to synthesise across data sources providing evidence for a given indicator.

FINDINGS

At the population level, we found reduced sales of higher strengths of controlled-release oxycodone and increased sales of other oxycodone formulations. No significant effect was observed among population-level indicators of opioid overdose, or help or treatment-seeking. Mortality data were not available for inclusion at the time of our study. Meta-analyses across sentinel populations (ie, prospective cohort, surveys of people who inject drugs, and clients of supervised injecting facilities or needle and syringe programmes) indicated reduced controlled-release oxycodone use via tampering (mainly injection), with no evidence of switching to heroin or other drug use.

INTERPRETATION

This formulation of controlled-release oxycodone reduced tampering with pharmaceutical opioids among people who inject drugs, but did not affect population-level opioid use or harm.

FUNDING

Mundipharma Australia, the Australian Government, and the National Health and Medical Research Council.